| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,867 |
382 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
201 |
$19K |
| D1110 |
Prophylaxis - adult |
477 |
473 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
786 |
779 |
$12K |
| D1120 |
Prophylaxis - child |
540 |
536 |
$10K |
| D0274 |
Bitewings - four radiographic images |
562 |
557 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
935 |
927 |
$7K |
| D0272 |
Bitewings - two radiographic images |
389 |
386 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
717 |
707 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
714 |
691 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
294 |
263 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
214 |
$4K |
| D0330 |
Panoramic radiographic image |
207 |
204 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
15 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
40 |
$294.00 |
| D0602 |
|
397 |
393 |
$0.00 |
| D0601 |
|
225 |
225 |
$0.00 |
| D0603 |
|
459 |
456 |
$0.00 |